Just when we thought the AHCA was dead in the water, it came roaring back to pass a May 4, 2017 vote in the House by a narrow margin. President Trump, badly bruised by the bill’s withdrawal without a vote about a month and a half earlier, desperately wanted a win…any win. In fact, it seemed like he didn’t even care what was actually in the bill as long as he could brag that he was fulfilling his campaign promise to repeal and replace Obamacare. So, yeah, he got a win—bigly. Evidently, he worked the bill hard.

Speaker Ryan, equally eager to show he could deliver after the March debacle, was willing to make a bargain with the far-right Freedom Caucus, the same group that sank his first attempt to pass the bill. So, yeah, Ryan got a win as well.

But the real winners of the March 4th vote were the members of the secretive House Freedom Caucus that held everyone else, including the President, hostage to their demands. What did they want? Nothing short of a full repeal of the ACA provisions that have recently given millions of Americans insurance coverage, some for the first time in their lives. No matter how much Trump tried to cajole and threaten them, they stuck to their guns and refused to vote for AHCA version 1.0.

“In a conference room in the Rayburn House Office Building, the group [the Freedom Caucus] met that evening and made a secret pact. No member would commit his vote before consulting with the entire group—not even if Trump himself called to ask for an on-the-spot commitment. The idea, hatched by Freedom Caucus Vice Chairman Rep. Jim Jordan (R-Ohio), was to bind them together in negotiations and ensure the White House or House leaders could not peel them off one by one. Twenty-eight of the group’s roughly three dozen members took the plunge.”

Because Republicans needed the Freedom Caucus votes to reach the threshold to pass the bill, their refusal to budge led to Ryan pulling the bill. People appalled by the bill breathed a sigh of relief. Some foolishly thought this meant Trump would move on to other things, but they were wrong. Repealing and replacing Obamacare is on his list of promises to keep. And, Republicans know that they can’t move onto tax reform without the cushion provided by the humongous tax cuts embedded in the ACHA.

What is the Freedom Caucus anyway?

The Freedom Caucus, also called the House Freedom Caucus, is a secretive invitation-only group of about 35 extreme right Congressmen. [There was one woman in the past, but she retired so it is now comprised of “old white guys” with the exception of Idaho’s now infamous Raul Labrador, a Hispanic.] Members’ names are usually not disclosed by the group and their meetings are not public.

An analysis by the Pew Research Center in October 2015 found that the members of the caucus had ideological scores based on roll call votes that were a third more conservative than the score of all of the other House GOP members. The least conservative member in the study, Steve Pearce of New Mexico, was more conservative than the average non-Freedom Caucus House Republicans.

Screenshot from PewResearch.org “What is the House Freedom Caucus, and who’s in it?” accessed 5/5/17

By banding together, consulting each other before they cast a vote, and holding firm against intense pressure to cave, this small minority of Republicans has garnered a disproportionate power that has resulted in the resignation of the prior Speaker of the House, John Boehner, and forced the current Speaker to withdraw the first version of the ACHA without a vote. They also agreed to hold firm on defunding Planned Parenthood even if it meant a government shutdown.

The Pew Research Center explains the arithmetic based on the math from the 114th Congress:

“Currently, Republicans have 247 seats in the House to 188 for the Democrats, which would seem to be a comfortable majority. But if the 36 (or more) Freedom Caucus members vote as a block against the GOP leadership’s wishes, their effective strength falls to 211 or fewer—that is, less than the majority needed to elect a new speaker, pass bills, and conduct most other business.”

So, how did they get the bill back on track?

The short answer is by adding two amendments: one to make the Freedom Caucus happy (at least happy enough to vote yes) and another to provide cover for Republican moderates who know that this bill is going to harm their constituents. The Republican leadership was able to flip enough no’s to yes’s to get the thing passed.

The first amendment, called the MacArthur amendment after the Republican who introduced it, is a provision that could subject some of the most important protections of the ACA to a state waiver process, including the ban on discriminating against people with pre-existing conditions and the essential health benefits mandate. This introduces the very real possibility of that these protections could be weakened so severely that millions of peoples will be unable to afford the same kind of comprehensive coverage that they have now. No surprise, supporters of the amendment say provisions of this type give people the freedom to choose the kind of coverage they want—if you believe that I have a bridge to sell you. In fact, this amendment frightened some moderate Republicans who threatened a nay vote, thus the need for the second amendment.

On May 3rd, Republican Congressman Fred Upton, who previously opposed the bill, introduced an amendment to add $8 billion over five years to help fund high-risk pools so people with pre-existing conditions wouldn’t end up priced out of the market. Even though many smart people know that this is nowhere close the amount of money to make high-risk pools work, it provided enough cover to flip a couple of nays to yays. The rest is history, the AHCA passed the house vote, 217 to 213. Although the bill as it is written is unlikely to get through the Senate without major revisions (or a complete redo), the win was enough for Trump to declare victory and throw a little party in the Rose Garden.

Celebrating AHCA vote at the White House (Freedom Caucus Chair Mark Meadows is to the left of Pres. Trump) (screenshot)

Why should we worry about what just happened?

Unlike the usual course of events for a bill as important as the AHCA—one that will impact almost 1/5 of the economy and affect many millions of people who have benefited from Obamacare—this bill was rushed to a vote without public hearings, without a CBO analysis to assess the impact of amendments added after the prior analysis, and, shockingly, with many members willing to vote for it even though they admitted publicly that they had not “thoroughly” read the bill.

This was political theater in all of its cynical glory, the kind of stuff that makes really good movies. But in real life, here’s what we should be concerned about:

The lessons learned from this vote are not likely to be lost on a President who wants to rack up wins regardless of the consequences to the nation.

As our President goes down his list of to-dos, he now knows exactly how he can show his base that he tried to give them what he promised during his campaign. All he has to do is give the Freedom Caucus exactly what they want. That is a very scary prospect for the rest of us.

Patricia Salber, MD, MBA is the Founder and Editor-in-Chief of The Doctor Weighs In. She is also a physician executive who has worked in all aspects of healthcare including practicing emergency physician, health plan executive, consultant to employers, CMS, and other organizations. She is a Board Certified Internist and Emergency Physician who loves to write about just about anything that has to do with healthcare.

2 COMMENTS

Given the Comey dismissal directly by the President — a move not made for nearly 30 years (then, it was Clinton firing Sessions for ethics violations) — your concluding paragraph might follow up with President Trump behaving like a Putin-esque dictator, or character from “The Godfather” with your quite appropriate tagline: “be afraid, be very afraid.”

It was Speaker Dennis Hastert who put in the rule that no legislation would be passed without a majority of Republicans. That informal, virtually parliamentary rule, is what gives the Freedom Caucus its power. Otherwise, bipartisan legislation would render them irrelevant.

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